FARDAH AKIL

“GI Disorders” Lecture in GERIATRI System, FKUH

 Diverticula can occur throughout the colon
 Most common near the end of the left colon
(sigmoid colon).
 Account for 30-55 % in developed countries,
extremely lower in areas such as Asia and
Africa.
 Burkitt and Painter in fact labeled
diverticulosis a ‘deficiency fiber disease’
Diverticular Disease (DD)
is a condition in which herniation of the mucosa
and submucosa occurs with relative weakness of
the serosa tunica lining whereas the vasa recta
penetrated from the colon wall.
 Aquired Pseudo diverticula
 Congenital True diverticula
 DIVERTICULA : more than one bulging sac (diverticulum)
 DIVERTICULOSIS : the condition of having these diverticula
in the colon
 PREDIVERTICULAR : mucosa /submucosa herniation still in
the colon wall
 DIVERTICULITIS : inflammation/infection in which diverticuli
in the colon rupture in the tissues that surround the colon,
mesentery, organs surrounding diverticulum or free
perforations of cavum peritonium.
 Based on AGE
≤ 40 y.o :2-5% mainly obeis ♂
60 y.o : 30 %
> 70 y.o : 50 %
> 80 y.o : 80 %
 Based on GENDER
age < 50 y.o : ♂ > ♀
age 50-70 y.o : ♀ less > ♂
age > 70 y.o : ♀ > ♂
Main factor :
low in fiber & low residue in diet
Function of the fiber :
~ increasing stool bulk more solid which are
shorter transit times and reduce intraluminal
pressure
~ substrat in bacterial fermentation to form
fatty acid short chain as mucosal energy and
incresing the blood circulation
~ to reduce the pain
 Small & hard feaces mass,
transit colon becomes slow

Water absorbsion ↑, intraluminal high

pressure

Increase segmentation of circular muscle colon

Occlusion both tip of the segmen,

increase intraluminal pressures

mucosa/submucosa herniation

DIVERTICULUM
 Increse of Age
decrease mechanic pressure of colon wall
result from collagen structure alteration

 Diet
high in meat, higher fat diets, smoking,
NSAIDs (risk of complication)
 Sigmoid colon 95 %
 Only sigmoid 65 %
 Near sigmoid 4 % → normal sigmoid
 All of the colon 7%
 70-75 % asymptomatic
 15-25 % diverticulitis & complication with
symptoms : left lower quadrant pain, fever,
leukocytosis
 Complication in the form:
phlegmon, abscesses (30-50% cases), obstruction (10%
cases), micro-macroperforations and fistula (2%) :
colovesicular, colovaginal, colocutaneus
 5-15 % with bleeding
 Generally have no physical symptoms, only
tenderness around the left side of the lower
abdomen
 Pain rebound : indication of peritoneal
irritation/inflammation result from micro-
macroperforations
 Mass palpable : inflammatory process spread
as a localized phlegmon or distant abscesses
can lead to peritonitis generalisata
A clinical grading system reflecting the degree of
perforation :

Stage I : Confined pericolic abscess.

Stage II : Distant abscess (retroperitoneal or pelvic).
Stage III : Generalized peritonitis caused by rupture of a
pericolic or pelvic abscess, noncommunicating”
with bowel lumen because of obliteration of
diverticular neck by inflammation.
Stage IV: Fecal peritonitis caused by free perforation of a
diverticulum (“communicating”).
 Asimptomatic Diverticular Desease often found
coincidentally through tests ordered for another
ailment (radiology / endoscopy or CT)
 60-70% DD with diverticulitis based on : fever,
left lower quadrant pain, mass palpable,
leukocytosis
 30-50 % X-ray in the form:
o small or large bowel dilation suggesting ileus/
bowel obstruction
o ↑ soft tissue densities suggesting phlegmon/
abscesses.
 Abdominal USG :
hypoechoic bowel wall thickening and cystic mass
(hyperechogenicity surrounding the bowel wall)
 Abdominal CT : definitive (sensitivity 69–95% &
specificity of 75–100%)
presence of diverticula with pericolic infiltration of
fatty tissue, thickening of the colonic wall, and
abscess/phlegmon formation.
 Intravenous contrast enema if invasive is seen so clear
(sensitivity of 62–94%) with false(-) ve 2-15%
 Colonoscopy
relative contraindication for acute
diverticulitis → perforation complicated
(bleeding stop after 12-24 hours)

 Selective Angiogram
moderate bleeding minimal 1-1,3 ml/minute
1. Medical
 A high-fiber diet / cereal bran (10-25gr/hr or
30-40 gr/hr) for asymptomatic /
simptomatic diverticular → improving the
symptoms & complication
 Decrease meat and higher fat diet
 Consume fruits and vegetables
 Avoid intake oral
 Intravenous fluid / electrolite therapy
 A broad-spectrum antibiotic

2. Surgery
Indication :
acute diverticulitis with continuous
complicated
Depending on the side of Diverticular Disease
 Colorectal carsinoma
 Acute Pyelonephritis
 IBS
 Ischemic colitis
 Appendicitis
 Pelvic Inflammation
 Haemorrhoid